Episode 179: Hypotonia & Its Impact on Oral Function

Hi and welcome to episode 179 of the Untethered Podcast. It's your host, Hallie Balkan. And today I wanted to answer a question that was posed when I asked what questions you all wanted answered on the podcast because I noticed this comes up a lot. The question was surrounding low tone and explaining how low tone relates to oral function and how we treat it differently or differentially diagnose it. Okay, so the first thing I want to say is I'm a speech pathologist, right? I'm not an ot, I'm not a pt, I'm not a body worker. However, I need to have a good understanding of low tone because I do work with soft tissues and we have to consider both tone and strength. And I see these terms get used interchangeably. So I wanted to take this episode to quickly deep dive into the difference between tone and strength, what we might see and then how we can. How we can differentially diagnose, but also treatment considerations. Right? Quick disclaimer. All information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. So let's first, diagnose or not diagnose. Sorry, let's define the difference between the two and the other thing I want to do is a little plug for the free training that's coming up because this always comes up during my free training as well. I am doing the five days of screening your first pediatric feeding patient. This will be the ninth time we've run it since 2020 and we only do it three times per year. It's coming up September 12th through, I want to say this Friday the 16th. It's a five day training. It's about an hour a day. First day is recorded. The days two through five are live on zoom and recordings will be available for about a week after that and then we take them down and it gets put into the course for anybody who joins the course. So I share that because I've been getting a lot of questions also about when is your next free training? My next free training is September 12, 2022. Go to feedthepedes.com backslash training to learn more about that. Okay. And you can always email us with questions@supporteedthepedes.com as well. So muscle tone and strength. All right, Muscle tone is the amount of tension or resistance to movement in our muscles. Another way of explaining that might be the amount of tension that's present when our muscles are relaxed as well as the ability of our muscles to sustain a contraction. This is different because muscle strength is typically that contraction in muscles while you're doing a physical activity or your muscles power. I've heard individuals say that in lower tone children. For example, I work a lot in pediatrics. We might see it as the muscles appearing a little droopy or sometimes the muscles might feel or look a little more squishy. They're lower tone, there's lower tonicity to them. Might have or what we call hypotonia. And they might also have more mobility in their joints. Okay. And that's not true of everybody, but that may be present now. I, for example, am a low tone individual. I have hypermobility in some of my joints. I have been diagnosed by some as having eds. I've also been diagnosed by some of us not having it and kind of being a borderliner on the cusp. Right. So it really sometimes depends, you know, who you're talking to. But I want to really clarify that muscle tone and muscle strength are two different things. Okay. Our, our muscle tone is going to help us hold our bodies upright when we are sitting, when we are standing. And if we have low tone, that's where you might start to see some children or adults, you know, sit more sloped over. They might have that pelvic tilt. Now this can be related to other things going on throughout the body as well. But we have to consider tone because if we have low tone, then it's going to become that much more important that we focus on strength, for example, because strength and focusing on that in our therapy can help to compensate for low tone and help individuals persist through activities of daily living. And for young children, one of those activities that could be something like play, right? Or engaging in a sport, running around on the playground. I once saw a really great video. I was on social media. I wish I remembered who posted this video. I don't want to just say like a random name and get it wrong, but it was a really great example of two brothers who were not far apart in age. They were pretty close in age. One brother went, hopped the fence, and he just like, like, flew right over it. No big deal. That child had normal strength and tone. His brother, however, tried to pop the fence in the same. Same way. And when he got to the fence, it's like it took him a couple extra steps to get to the top, get himself over. Now he was able to complete the activity. And it's not that he had less strength, but he had lower tone. And so it made it that much more challenging for him to get over the fence. Right? He didn't do it with the same grace and speed, if you will, as his brother. Now, could he learn over time through building strength and through practice? Maybe. Could he overcome that? Maybe. Possibly. But we have to understand is that we can't change low muscle tone, right? We can change strength. And so then it really comes down to, okay, how does this impact us in a differential diagnosis, in the work that we do? Right? How do we differentially diagnose between a child who may have low tone tone or who may have regular tone but still present with either speech issues or feeding issues or orofacial myofunctional disorder, you know, myo issues or sleep or what, you know, whatever. Whatever may be on the table for that individual. The other thing that I found interesting, too, because I was Googling around, I wanted to see, like, how different websites define tone versus strength. I think it's a really interesting conversation because I find that it can be really confusing. One website versus the next has a different definition, and sometimes they include different points that, again, it's a little confusing. Right? One of the things Cleveland Clinic mentioned was that low tone in and of itself, like, hypotonia is not a diagnosis. Cysts. And I was like, huh. This is interesting because, like, we've talked about how, you know, colic, for example, is not a diagnosis per se. Right. It's. It's a result of something else going on. And so it. It sounds as though tonicity, even though it's something that can't really be changed. Low tone in and of itself is not a diagnosis. Diagnosis that has, like, a disability code per the Cleveland Clinic. Okay. I really didn't get too deep into looking beyond that. I'm, like, sitting here going, I wonder if there's an ICD. ICD 10 code for hypotonia. Because I believe there is. I'm pretty sure in my practice we've had children who do have a diagnostic code. So again, I just share this And I'm not sharing this as like 100% fact or not fact, because that's what it said on the Cleveland Clinic and it said that. It said low tone is not a diagnosis. It said that it's not a disability, that there could be an underlying disability or diagnosis. And I guess that they look at it as though because hypotonia doesn't affect a person's intellectual disabilities, maybe that's a reasoning for why they they felt that it's not a diagnosis, but there is actually an ICD10 diagnostic code for it. So I'd be so curious to hear from OTs, like, what is, what is there debate surrounding this topic? I really. I'd be curious to know. Ok. Okay. So what does it look like? So we kind of talked about the key difference in that muscle tone and muscle strength. Right? That difference is the muscle tone is that total tension that is present in the muscle tissue during relaxation versus strength is that ability to collect like the power of all the muscle tissue during movement, during active movement. Right. So there'd be like forces of like pushing or pulling or lifting or just like movement in general. So I just want to kind of refresh your memory on that one. And hopefully that explanation helps to separate and explain the differences between the two. And again, we can't change tone, but we can change strength. And changing strength may help us compensate for low tone. So what are some characteristics of low tone? Well, we talked about there might be some joint hypermobility. Right. That can also lead to joint instability. And we can see this throughout the body. Right. Think about what we deal with in feeding or myo or speech. We have to consider that temporomandibular joint. That's a pretty big joint over there that connects the upper and lower jaw. Right. We might see our kids or adults with a slouch sitting posture. We might see that w sitting where the legs are flipped backwards, like the lower half, the legs sit backwards, the knees are pointed forward, and the child is. Their bottom is on the floor in between with their legs out in that w sitting posture, which is basically giving them a wider base of support. We might see difficulty holding the head upright. People like myself might prop their head on their hand, especially when they start to fatigue more. They might notice that they have a difficulty standing for longer periods of time or even sitting for longer periods of time. They may prop themselves up with their arm or sit up against something. When sitting on the floor, they might perform certain motor tasks with too much force or even too little force. They may Appear incoordinated or even clumsy at times. I gave you that example of the two brothers. They may have difficulty climbing or running or jumping or hopping. When you look at them next to their same aged peers that have typical tone, they may have trouble with speech sound production because again, we have to use the muscles in our face. We can't use the muscles in our face properly to produce the movement needed for sounds. Right? We start to go, huh, okay, maybe some of those age expected speech sounds might be impacted. Sometimes we see these kids with a open mouth posture due to their low, their low tone. And so then we may also see excess drooling and then it can absolutely impact the ability to chew and feeding in general. Everything from the, you know, taking food off of a spoon, biting, biting food, you know, we may see impacted strength. And that's where strength, like even taking a bite of food and then, you know, chewing and sustaining the chew. Right? Getting the food prepped into a bolus to swallow and then actually swallowing it, then the body needs to be able to move the food throughout the digestive tract. And so there again can be low tone throughout various parts of our body. It's not typically just in one place. When I've seen low toe in children, I see anywhere, I see, you know, like maybe their cheeks sit a little bit lower. Some people say they have droopy cheeks, their mouth might be open, they may be drooling. It'll just appear as though certain tasks might be harder for them or like as if they take more energy to chew, to swallow, to speak, to keep their mouth closed, to nasal breathe, to get their tongue up on the palate and have it rest up there. Right. And so again, we are not going to change tone per se, but we can wake the body up, we can bring attention to an area that we want to work on in therapy and we can absolutely build strength as a compensatory method to help an individual have more energy to produce the tasks that they need to on a daily basis. So again, what, what can we do? Right, well, as far as ways to improve strength, you know, and, and let me go back for a second because there was a question of how do we differentially diagnose, is it possible that somebody with an open mouth posture who's drooling, who struggles with some, some of these things I mentioned, is it possible that they have normal tone and they reduce strength or they have normal tone and it's just a habit because let's say they had a cold, they started mouth breathing and now They've been mouth breathing for six months when they used to nasal breathe. Or maybe they were just. They were born with their mouth open. Sure. We may see children with. And I haven't looked into the research. I don't know if it exists, to be completely honest, but I haven't looked to see if there's research between tether neural tissues and low tone, specifically, without anything else, you know, in the mix, like as I go to Google Scholar, and I know many of you will do this too, as I'm talking. But the point is, I'd be so curious to see, are the individuals who are epigenetically have more of these tethered oral tissues presenting, Are they also individuals who present with low tone? Right. Is there a higher correlation? And again, I'm not saying there is. I'm just throwing it out there. If somebody wants to do research on this, by all means. You know, tongue tie and low tone or hypotonia, I'm over here looking it up as we speak. There is more coming out on tetheral tissue, specifically tongue tie as well. But in terms of hypotonia, again, I have not seen anything specifically tied to tetheral tissues. So I'm going to venture out to say that they can exist separately. One is not necessarily positive of the other. I believe they're two separate things. That's my opinion. So we do need a differentially diagnosed. Right. And can they have both? Can you have both hypotonia and tether dural tissues? It is my belief that, yes, you can. So we need to look at the individual. Right. And we also need to look, we need to look beyond just what's going on in the face. A lot of my OT colleagues and I know in the feed the peds course, we will, you'll hear us say things like what you see on the lips you see on the hips, or what you see on the hips you see on the lips and vice versa. And there's other cute phrases like that, too. Well, the point behind this saying is that if we feel that they are, they've got, you know, a tilted pelvis, they are slouched over or sitting too far forward. Right. 1. The ability to nasal breathe may be impacted by the position of the hips. Like if you push your pelvis forward and breathe, you may feel some resistance. Right? Then if you slouch backwards and breathe, it might be a little bit easier to breathe, depending on your tone. I'm low tone for me. It's actually, it feels a little bit easier for me. To breathe when I have an anterior pelvic tilt versus a posterior pelvic tilt, then if I sit up nice and straight, that provides the least resistance for me, even though I am a low tone individual. So considering how a child is breathing and their posture. Right, and now is there, are they breathing through their nose or their mouth? Are they doing this awake versus asleep? Where is their tongue? Is the tongue on the floor of their mouth? Do we feel like it's a low tone issue and they're having a hard time sustaining the tongue up in the palate because of tonicity, or do we feel like it's there's tethered oral tissues present that's holding the tongue down? Right. Like we do have to ask these different questions and there's many more questions to ask. I'm just giving you an example of what we need to consider when looking at these children. We don't want to just assume that because a tongue is sitting on the floor of the mouth and a child or adult is mouth breathing, that they're low tone or that they have a tongue tie. No, we need to differentially diagnose. We need to examine physically, we need to do an orofacial examination. And then we also need to look at functional impact. Right. We need to look at how is this impacting them in their daily life and, and is there more of a full body impact? Does it go beyond what we're seeing on the face, what we're seeing in the mouth? Does it go beyond the impact on their sleep or speech or feeding or whatever it is that we might be looking for? Do we need to refer to an OT colleague, a PT colleague, somebody who's going to look at tonicity and various parts of the body based on, you know, if we see a kid is struggling to walk up the stairs, got a two year old who has a hard time walking up the stairs. We're probably going to make a PT referral. If we've got a kiddo who seems kind of floppy and is having a really hard time sitting up and they're having a hard time with that trunk control and fine motor skills, we're going to refer to our OT colleagues, maybe we're referring this child to both, right? Who knows? It really depends on the individual child. I say all this because we need to consider who the patient is that's sitting in front of us and we need to also consider what is their functional impact. Right. And who do we feel like the best individuals for this child's team may be. So what can we do in therapy. Well, we have to consider a couple things. And this was a question that actually came up in my MILE membership last week where somebody had asked a question about a child with down syndrome and are there any contraindications in terms of a tongue tie release? Again, we have to consider that, yes, because they have a Down syndrome diagnosis, they traditionally are going to present as low tone. Right. They're going to have hypotonia. However, does this mean that if a child is low tone or they have down syndrome or something else is going on, that they are not a candidate for a tongue tie release or expansion or any of the things we do in the myo world? Not necessarily. But you have to know your patient, does that child have the cognitive ability to participate if their cognition is at a certain level, if they have at least the cognition of a four year old? Right. And I'm not talking about chronological age, talking about cognitive ability. Two very different things. And they can follow directions or maybe they're really good at imitating in the mirror. Right. And they'll copy anything you do, even at a younger age. Right. Even. I've worked with children. I had this one little guy that I worked with who had down syndrome. We worked together when he was in, he was 2 and he was able to copy and imitate everything I did in the mirror. Like he was my little tongue click friend, clicking away with his tongue. Absolutely amazing. And it was really cool because we were able to prep him actually easier than his brother, who also had some low tone and a sensory processing disorder. He was more quickly prepped for a tongue tie release. And I had no concerns that the tongue would fall back and block his airway following a release, which is typically what the concern is. And this was the question that was asked last week in my group. They said, well, I was told that we don't release children with down syndrome because they're low tone. And then the tongue is going to fall back in the air airway when they're sleeping, they're not going to be able to keep their tongue up in the palate. Well, this is why pre op therapy is an, is a must. Not just for that population, but for anybody. We should not be just releasing tongues unless we are pretty confident that either, one, we can't go any further, and two, that tongue is not going to fall back in the airway and block the airway and cause further obstruction for that patient following a release. Right. So this, I know many therapists who feel a little bit, I want to say frightened Maybe hesitant, right, to sometimes make this call because they don't want to make the wrong call. And sometimes we don't really know until following a procedure. So we need to be doing everything in our power to really confirm on our end that we feel confident with that child proceeding and that they are truly prepped. And I got another question about what was it? It was what's involved in pre and post release therapy? We've talked about that on the podcast. So I would, I would suggest you go to untethered podcast.com and just google pre op or search the word pre op or post op or frenectomy and you'll see all the episodes that have that, you know those keywords or they have it in the title. But we talk specifically about the necessity of pre op therapy and post op in various episodes. So I'm not going to go into that specifically other than to say it's necessary. And we see the difference. And the children who get it versus those who don't. There's a big difference. Adults as well. But I know we keep focusing back on our pediatrics. What can we do? What can we do to help these kiddos? And what can we do to improve strength? How do we treat them therapeutically? I would look at strength and my OT and PT colleagues. I know that they'll work on more of the, the limbs and the core. And that's really important because remember what I just said? I just said that what we see on the hips, we see in the lips. And so having a PT or an ot, working with that child based on their, their needs, you know, is it the core, is it the limbs? What is it? You know, some of my OT colleagues, I'll see them have it, have a child do like heavy work. Maybe they'll push or pull like a heavy object. They will work on, you know, work on the playground with them or on different types of equipment. They will have them bear walk or crawl. They'll have them climb a rock wall or monkey bars and, and again, this may be PT or ot, but that those climbing and crawling and pushing and pulling activities, they help to work on muscle strength for these children, which again becomes compensatory for the low tone, which we can't change. If you remember, I talked about how some of these kids are not so coordinated, right? So learning how to jump side to side, forward, backward, frog jumps. I've seen some of that and there's, there's a lot more that goes on as well. I know that some of my colleagues also recommend Extracurricular activities like swimming or karate or even gymnastics, I think has been another good one that's been recommended for some of these children because it, it can help them stay on track developmentally with motor skills. And it's fun, right? Some of these things are fun for the children to do. But like, what do we do in feeding or myo or speech? Well, we also, surprise, surprise, need to work on strengthening muscles. And there is such a big discussion on this topic and almost, it seems like a 50, 50 split in the speech pathology industry, which is, it's comical to me. It's comical that in every other industry it is well accepted and appreciated and understood that you need to build strength, right, in order to help children who have low tone. But in the speech pathology world, you know, we, we say, okay, well, if there's jaw instability, right? And low tone, right? The cheeks are low tone, the jaw is not. Will we see sliding of the jaw or gliding where we really want to see some stability gained. We know those of us who work on jaw stability, those of us who work on lingual control, those of us who work on building strength and coordination and control of the orofacial muscles, we know that that positively impacts speech production, that positively impacts the ability to chew and swallow your food, that positively impacts the ability of the tongue to resp up in the palate and keep those lips closed and nasal breathe, assuming that the nose is patent, right? We know the positive impact that it has, yet it's still, for some reason, that's really interesting to be. So I share all this because I want to be very clear that we can absolutely work with these children and they in fact need the therapy arguably more than maybe some, some other children, right? Not to say that one child needs it more than another, but when they have low tone, the therapy to address strength, because strength is going to become that compensatory method that they need to build and use in order to accommodate the low tone, right? We can't change muscle tone. We can wake up the muscles. We can take them out of a state of relaxation, right? But then we're actively engaging them, okay? And remember, that key difference is that muscle tone and muscle strength, right? The two of them. Muscle tone is that total tension at rest. That's a total tension that's collected in the muscle tissue of the child at rest during relaxation, right? Versus muscle strength is that collected power of the muscle tissue that, that appears when we engage it. When we are active, when we push, we pull, we lift, right? And we move the body, okay? So we need to remember. And I will tell you as I've been sitting here recording this for, oh, I don't know if it's been 30 minutes yet. I am getting fatigued. My core is more slouched over than when we started. And if you watch my videos, okay, and I know you're all going to go and watch the clips on. On Instagram. If you go look at my video clips on Instagram, you will notice that I have a tendency to lean into the computer. One, it's. It's just how I engage sometimes when I'm talking to individuals and when I get really into what I'm doing. But two, it's my low muscle tone in my stomach that I sit. I sit forward in my chair. So I have a X chair, which is specifically for giving me the ability to support myself and the posture that I require to sit at a computer when I'm working. However, when I'm actively talking, I tend to sit forward. I kind of go into a pelvic tilt, despite the fact that I've got this wonderful chair here to support me. And then I'm. And then I feel like I'm talking, like, into the camera and my head is like, basically the entire screen. So you guys are going to laugh. You're going to go. You're going to see this. When you look at my clips that, that we pull and put on Instagram, you will see that I have this more like, head forward posture. And I will tell you it's not airway for me when I'm recording these things because that's not how I always sit. I do sit with poor posture, and I do need to remember to, like, stand up straight, keep my shoulders up. Like, I do have to physically work on that and build core strength to make up for the low tone. Right. But it has not impacted my intelligence, my cognition. It has not impacted my ability to be successful in life. It's made some things more challenging. Like, I'm not very good at sports and really don't have much of an interest because I feel like I've always had to exert that much more energy over others. But I did gymnastics when I was younger, and I loved it because it was a supportive thing for me. Now, I didn't get all crazy, you know, and go, like, competitive and all that fun stuff. But this is the type of thing where we have to look at what activities are, what activities will best support the patient or the child sitting in front of us. Right. What can we do to help build strength to make up for that low tone. Right. These children are not to be written off or adults. Hi, I'm adult. I have low tone and hypermobility in my joints. We need to consider, though, that if they have hypermobility, if they have low tone, their therapy may look a little different. Or we may need to consider, okay, what else do we need to do for this patient that maybe we didn't need to do for the other one that didn't have low tone? Right. Does it mean that we don't work with them? No, it doesn't mean that, but we should be looking at every patient and their response to screening, assessment, intervention, therapy. How do they respond? And if something is not working, what can we as therapists change to help them achieve the end goal? This is where therapy becomes a combination of art and science. Because we have to get really, really comfortable with moving away from what we've learned and what we understand to be true to trying different things and saying, hey, you know what? I might have learned that this exercise is really helpful for lateralizing the tongue, but this patient's really struggling. So what else can I try to see if I can help this patient learn the motor movement and then see if I can fade that and if they can sustain it themselves? Right. Or do we need to continually work at it until enough strength has been built that they can compensate for what their tone is not allowing for in this situation? And sometimes these kids spend a lot longer in therapy. Right. So, again, know who that child is that's sitting in front of you. There's no hard, fast rule here. We don't ignore these kids or write them off for tongue tie releases or myotherapy or feeding therapy. No, in fact, these are the patients that we need to pay greater attention to that we need to be willing to mix things up a bit so that we can help them build strength, compensate better for what their tone is not doing for them. Right. So I hope that that's helpful, and I hope that really lays the groundwork and the understanding of the difference between muscle tone and muscle strength. And when we start to think about what that looks like in other parts of the body, that can also help us understand the orofacial complex a bit better and how to approach it. If you guys have ongoing questions about tone versus strength, let me know. This is. This is basically the level of understanding that I have. So I'll be happy to pass it along to one of our ots on the. To help them explain a little bit better. Because again, I'm an SLP and my my greatest understanding really comes from seeing what my colleagues are doing full body but also you know is limited to what I do in the orofacial complex really from my I feel like the neck up okay, so I hope this was helpful. I will see you all on the next episode. As always, if you have questions you want answered on the podcast, submit them to supporteedthepeds.com we will have some more guests coming up on the podcast this fall after we wrap up our little mini series here on some very specific topics that you all have been asking about and we look forward to chatting with you on future episodes. Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com or if you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page @HALLIEBLCAN BIZ, on Instagram at Ali Bulkin. And you can head over to theuntetheredpodcast.com to grab a copy of the Show Notes where you can also subscribe to be kept up to date on the latest podcast episodes.